CLAIM FOR LOST, STOLEN OR DESTROYED UNITED STATES SAVINGS BONDS

Transcription

1 For official use only: Customer Name E Department of the Treasury Bureau of the Public Debt (Revised March 2008) Customer No. CLAIM FOR LOST, STOLEN OR DESTROYED UNITED STATES SAVINGS BONDS OMB No Visit us on the Web at IMPORTANT: Follow instructions in filling out this form. You should be aware that the making of any false, fictitious, or fraudulent claim or statement to the United States is a crime that is punishable by fine and/or imprisonment. PRINT IN INK OR TYPE ALL INFORMATION 1. DESCRIPTION OF BONDS Describe the missing bonds in the spaces below. If you don t know the bond serial numbers, provide as much information as possible and also indicate the total number of bonds that are missing. ISSUE DATE (If you don t know the exact date, furnish a range of issue dates.) FACE AMOUNT BOND NUMBER INSCRIPTION (Provide complete Social Security Number [for example, ], names, including middle names or initials, and addresses on the bonds) (If you need more space to describe your bonds, use the continuation sheet on page 6.) 2. DETAILS OF THE LOSS Mark the appropriate boxes and provide complete details of the loss. Lost The bonds were: Stolen Destroyed Date of Theft: Was a police report filed? Yes No If Yes, attach a copy of the report. Send any remaining pieces with this form. When was the loss discovered? Who had the bonds last, and why? Who had access to the bonds? What was the result of your inquiry to the person(s) who had access? Where were the bonds last placed? When were the bonds last seen? Were any identification documents also lost or stolen? Yes No If Yes, please list them: Have you received reimbursement because of the loss? Yes No Please explain, including details of any court proceedings pending or contemplated.

2 3. AUTHORITY Provide details regarding your authority to complete a claim for the missing bonds. Are you named on the bonds? Yes No If Yes, skip to Item 4. If No, provide the following information: Describe your authority: (Show authority: i.e., parent, guardian, conservator, legal representative, administrator, executor, etc.) Are you court-appointed? Yes No (If Yes, see LEGAL REPRESENTATIVE in the Instructions.) 4. MINORS Provide details regarding any minor named on the bonds. (See MINORS in the Instructions.) Is there a minor named on the bonds? Yes No If No, skip to Item 5. If Yes, fully complete the following: What is the minor's : Name? Social Security Number? What is your relationship to the minor? Does the minor live with you? Yes No DOB? If No, with whom? (Name) (Relationship to Minor) (Address) Who provides the minor's chief support? (Name) (Relationship to Minor) (Address) Are both parents able to sign the application for relief? Yes No If Yes, skip to Item 5. If No, fully complete the following: Why are you unable to obtain the signature? Did that parent have access to the bonds? Yes No Could that parent have possession of the bonds? Yes No 5. RELIEF REQUESTED Indicate whether substitute bonds or payment is desired. (See Item 5 in the Instructions.) I/We hereby request: Substitute Bonds Payment by Check Payment by Direct Deposit Name(s) in which check is to be drawn: 6. DELIVERY INSTRUCTIONS Complete only Item 6A or 6B. A. MAIL BONDS OR REDEMPTION CHECK TO: (If bonds are in coownership form, see Item 5 in the Instructions.) (Name) (Number and Street, Rural Route, or PO Box) (City) (State) (ZIP Code) B. DIRECT DEPOSIT FUNDS AS AUTHORIZED BELOW: (Name/Names on the Account) (Depositor's Account No.) Type of Account: Checking Savings Bank Routing No. (Financial Institution's Name) (Phone No.) (2)

3 7. SIGNATURES AND CERTIFICATION I/We severally petition the Secretary of the Treasury for relief as authorized by law and, if relief is granted, acknowledge that the original bonds become the property of the United States. Upon the granting of relief, I/we assign all our right, title, and interest in the original bonds to the United States and bind myself/ourselves, my/our heirs, executors, administrators, successors and assigns, jointly and severally: (1) to surrender the original bonds to the Department of the Treasury if they are recovered; (2) to hold the United States harmless due to any claim by any other parties having, or claiming to have, interests in these bonds; and (3) upon demand by the Department of the Treasury, to indemnify unconditionally the United States and repay to the Department of the Treasury all sums of money which the Department may pay due to the redemption of these original bonds, including any interest, administrative costs and penalties, and any other liability or losses incurred as a result of such redemption. I/We consent to the release of any information in this form or regarding the bonds described to any party having an ownership or entitlement interest in these bonds. I/We certify, under penalty of perjury, and severally affirm and say that the bonds described on this form have been lost, stolen, or destroyed, and that the information given is true to the best of my/our knowledge and belief. Sign Here You must wait until you are in the presence of a certifying officer to sign this form. (Signature) (Print Name) Home Address (Social Security Number) (City) (State) (ZIP Code) (Daytime Telephone Number) Check "YES" to give us permission to contact you by or check "NO" if you do not wish to be contacted by . Yes No Address Sign Here Home Address (Signature) (Print Name) (Social Security Number) (City) (State) (ZIP Code) (Daytime Telephone Number) Check "YES" to give us permission to contact you by or check "NO" if you do not wish to be contacted by . Yes No Address Sign Here Home Address (Signature) (Print Name) (Social Security Number) (City) (State) (ZIP Code) (Daytime Telephone Number) Check "YES" to give us permission to contact you by or check "NO" if you do not wish to be contacted by . Yes No Address Certifying Officer The individuals must sign in your presence. Complete the certification and affix your stamp or seal. I CERTIFY that, whose identity is known or was proven to me, personally appeared before me this day of,, (Month) (Year) at, and signed this form. (City) (State) (OFFICIAL STAMP OR SEAL) (Signature and title of certifying officer) (3) (City) (State) (ZIP Code)

4 I CERTIFY that, whose identity is known or was proven to me, personally appeared before me this day of,, (Month) (Year) at, and signed this form. (City) (State) (OFFICIAL STAMP OR SEAL) (Signature and title of certifying officer) I CERTIFY that (City) (State) (ZIP Code), whose identity is known or was proven to me, personally appeared before me this day of,, (Month) (Year) at, and signed this form. (City) (State) (OFFICIAL STAMP OR SEAL) (Signature and title of certifying officer) (City) (State) (ZIP Code) Customer Account Number and Date Established: RESERVED FOR IDENTIFICATION NOTATIONS Document(s) Description: Identified by (Signature and Address): INSTRUCTIONS TO CERTIFYING OFFICER Each person appearing before you must establish identification by positive and reliable evidence before this form is signed, unless he or she is personally known to you. Place an adequate notation above or on a separate record, showing exactly how identification was established. A notation is adequate if it is sufficiently detailed to permit, at a later date, a determination of the exact identification actually used. You and, if you are an officer or employee of an organization, the organization will be held fully responsible for the adequacy of the identification. The signatures to the form must be executed in your presence. Fully complete and sign the certification form provided for each signature you witness. If you are an employee (rather than an officer) authorized to certify signatures, insert the words Authorized Signature in the space provided for the title. Insert the place and date, as required on the form, and impress the seal of your organization. PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE The collection of the information you are requested to provide on this form is authorized by 31 U.S.C. CH. 31 relating to the public debt of the United States. The furnishing of a social security number, if requested, is also required by Section 6109 of the Internal Revenue Code (26 U.S.C. 6109). The purpose of requesting the information is to enable the Bureau of the Public Debt and its agents to issue securities, process transactions, make payments, identify owners and their accounts, and provide reports to the Internal Revenue Service. Furnishing the information is voluntary; however, without the information Public Debt may be unable to process transactions. Information concerning securities holdings and transactions is considered confidential under Treasury regulations (31 CFR, Part 323) and the Privacy Act. This information may be disclosed to a law enforcement agency for investigation purposes; courts and counsel for litigation purposes; others entitled to distribution or payment; agents and contractors to administer the public debt; agencies or entities for debt collection or to obtain current addresses for payment; agencies through approved computer matches; Congressional offices in response to an inquiry by the individual to whom the record pertains; as otherwise authorized by law or regulation. We estimate it will take you about 20 minutes to complete this form. However, you are not required to provide information requested unless a valid OMB control number is displayed on the form. Any comments or suggestions regarding this form should be sent to the Bureau of the Public Debt, Forms Management Officer, Parkersburg, WV DO NOT SEND completed form to the above address; send to correct address shown in "WHERE TO SEND" in the Instructions. (4)

5 INSTRUCTIONS PURPOSE OF FORM Use this form to apply for relief on account of the loss, theft, or destruction of United States Savings Bonds. "Bonds," as used on this form, refers to Savings Bonds, Savings Notes, Retirement Plan Bonds, or Individual Retirement Bonds. WHO MAY APPLY This form must be completed and signed by all persons named on the bonds, or by an authorized representative. ATTACHMENTS If more space is needed for any item, use a plain sheet of paper and attach it to the form. PROOF OF DEATH If a registrant is deceased, a certified copy of his/her official death certificate must be submitted with this form. LEGAL REPRESENTATIVE If you were appointed as legal representative because: the owner is deceased (with no surviving coowner or beneficiary named on the bonds), or the owner or coowner is a minor, or the owner or coowner is incapacitated, complete the form and submit a court certificate or certified copy of your letters of appointment, under court seal, showing the appointment is still in full force. If your name and official capacity are shown in the registration of the bonds, evidence of your appointment is not necessary. If no legal representative has been appointed for a deceased or incompetent owner, advise the Bureau of the Public Debt and additional instructions will be provided. MINORS If a minor (who does not have a court-appointed guardian) is named on the bonds, the minor must complete and sign the form on his/her own behalf if, in the opinion of the certifying officer, he/she is of sufficient competency and understanding to comprehend the nature of the transaction. Otherwise, the form must be signed by both parents on the minor's behalf. If the minor does not reside with either parent, the form must be completed and signed by the person who furnishes the minor's chief support. SOMEONE ELSE HAD THE BONDS If another person had possession of the bonds or knowledge of the circumstances of the loss, that person must provide a separate statement explaining the circumstances. AMOUNT OF BONDS EXCEEDS $5,000 If the amount of the bonds involved exceeds $5,000 and an investigation was made by a law enforcement agency or an insurance, transportation, or similar business organization, provide a copy of the report. COMPLETION OF FORM Print clearly in ink or type all information requested. ITEM 1. Describe the missing bonds. If you don't know the bond serial numbers, indicate the total number of missing bonds and provide as much of the requested identifying information as possible. ITEM 2. Mark the appropriate boxes and provide complete details of the loss, theft, or destruction. ITEM 3. Provide details regarding your authority to complete a claim for the missing bonds. If you have been court-appointed, see "LEGAL REPRESENTATIVE" above. ITEM 4. Complete this item if a minor is named on the bonds and he/she is not of sufficient competency and understanding to complete the form on his/her own behalf. Provide the minor s name, date of birth, Social Security Number, and all other requested information. See "MINORS" above for more information. ITEM 5. Indicate whether you want substitute bonds, payment by check, or payment by direct deposit. If you select payment by check and the bonds are in the names of living coowners, provide the name of the coowner to whom the check should be issued. Otherwise, if both coowners sign the form, the check will be issued to both coowners and interest will be reported under the first-named coowner s Social Security Number. Complete Item 6A to provide delivery instructions for the bonds or check. Complete Item 6B if payment by direct deposit is preferred. NOTE: Series EE and Series I bonds issued February 2003 and later are not eligible for payment until one full year after issue; if payment is requested and such bonds are less than one year old, substitute bonds will be issued instead. Also, if substitute bonds are requested and a bond is within less than one full calendar month of reaching its final maturity, payment will be made instead. ITEM 6. Complete Item 6A to provide mailing instructions for the bonds or redemption check or complete Item 6B to provide instructions for direct deposit of the redemption payment. ITEM 7. Each person whose signature is required must sign the form in ink, print his/her name, and provide his/her home address, Social Security Number, daytime telephone number, and, if applicable, address. Each signature must be certified (see CERTIFICATION below). CERTIFICATION Each person whose signature is required must appear before and establish identification to the satisfaction of an authorized certifying officer. The signatures to the form must be signed in the officer's presence. The certifying officer must affix the seal or stamp, which is used when certifying requests for payment. Authorized certifying officers are available at most financial institutions, including credit unions, in the United States. For a complete list of such officers, see Department of the Treasury Circulars, Nos. 300 and 530, and Public Debt Series, Nos and WHERE TO SEND Send the application and any additional information to the Department of the Treasury, Bureau of the Public Debt, using the address listed below that is appropriate to the type of security involved: HH/H savings bonds PO Box 2186, Parkersburg, WV E/EE/I savings bonds PO Box 7012, Parkersburg, WV Note: The instruction page (5) and the continuation page (6), if not needed, may be retained. For Bond-Related Inquiries: Phone: (304) Fax: (304) (5)

6 Continuation of description of bonds in Item 1: ISSUE DATE (If you don t know the exact date, furnish a range of issue dates.) FACE AMOUNT BOND NUMBER INSCRIPTION (Provide complete Social Security Number [for example, ], names, including middle names or initials, and addresses on the bonds) (If you need more space to describe your bonds, use a continuation sheet and attach it to this form.) (6)

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